The Science of Training in Evidence-Based Treatments in the Context of Implementation Programs: Current Status and Prospects for the Future

Abstract

Training plays a critical role within the broader implementation research agenda involving evidence-based treatments (EBTs). EBTs, interventions that have demonstrated client improvement within the context of controlled trials (Kazdin 2008), tend to be complex, multisession treatment packages that hinge largely on the provider’s execution of a set of interventions with a satisfactory level of fidelity (Carroll et al. 2010; Chorpita and Regan 2009; Herschell et al. 2010). Although training alone is not sufficient to guarantee successful implementation, there is evidence that adequate training can reduce variations in provider behavior, improve fidelity, and ultimately, increase the quality of service delivery (Aarons et al. 2011; Feldstein et al. 2008; Fixsen et al. 2005; Stirman et al. 2004) above and beyond that provided by therapy as usual (Schoener et al. 2006; Simons et al. 2010). In light of the central role training plays in the implementation of EBTs in mental health service delivery settings (Karlin et al. 2010; McHugh and Barlow 2010), efforts to scientifically examine the impact of training and to establish best practices in training are essential (Herschell et al. 2010). Our field is fortunate to be at the point at which EBTs have been designed, tested, and refined with much success; however, dissemination and implementation initiatives are still in their relative infancy (Becker et al. 2009). This early stage of evidence-based training development renders the field at a crossroads. One possible path parallels the traditional stage model of EBT development (Onken et al. 1997), with training methods developed and tested in university-based settings with tightly controlled conditions to demonstrate efficacy prior to testing effectiveness. As demonstrated by highly controlled studies of training (Miller et al. 2004; Sholomskas et al. 2005), this approach has merit inasmuch as information regarding necessary and sufficient training components, and optimal dosage, sequencing, and spacing of training can be identified (see Rakovshik and McManus 2010 for a review of these factors in the training of cognitive behavioral therapy). However, as the stage model of psychotherapy development has demonstrated, the needs of the field, in terms of understanding effective, efficient treatment strategies that can be deployed in less tightly controlled settings, easily outpace the stages of research (Institute of Medicine 2001). Similarly, given that advances in EBTs have outpaced the development of implementation supports (i.e., evidencebased training) (Fixsen et al. 2005), the ‘‘research-topractice gap’’ (McHugh and Barlow 2010) is at risk of continuing to widen, leaving a workforce with insufficient training and support in the very treatments that may have the best chance of improving the conditions of patients in need. An alternative path to promoting the science of training involves fitting the training program into the existing mental health delivery system (Stirman et al. 2010) to K. D. Becker (&) Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, 8th Floor, Baltimore, MD 21205, USA e-mail: kbecker@jhsph.edu